The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

BAYLOR REGIONAL MEDICAL CENTER AT PLANO

4700 ALLIANCE BOULEVARD PLANO, TX 75093

April 3, 2012

VIOLATION:RN SUPERVISION OF NURSING CARE

Tag No: A0395

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of documentation and interview with staff, it was determined that nursing staff failed to follow a physician's order to be notified if pain control was ineffective for patient #1.

Findings included:

A review of the medical record revealed patient #1 was admitted for uncontrolled pain after having back surgery on 12/12/11.

A review of the medical record revealed there was a physician's order dated on 12/12/2011 at 2:20pm. This order stated, "Notify staff member #2/staff member #1 if...pain not controlled with medications." The orders were signed by staff member #1. Staff member #2 was the surgeon for patient #1.

A review of the medical record revealed a telephone order dated 12/14/2011 at 3:00pm from physician #3 revealed "Dilaudid 1 mg IV q4 (every 4 hours) PRN, Dilaudid 2-4 mg po q6 (every 6 hours) PRN." Noted by a nurse and signed off by staff member #3 on 12/27/2011.

There was no documentation found in the medical record of patient #1 or provided to the surveyor to indicate that the nursing staff notified staff member #1 or staff member #2 that the patient was having problems with pain control as specified by the physician order dated 12/12/11.

In a telephonic interview on 4/3/12 at approximately 4:30pm with staff member #1, it was confirmed that the nursing staff did not notify either staff member #1 or staff member #2 that patient #1 was having problems with pain control. Staff member #1 stated staff member #2 wants to be notified when patients are having problems with pain control. Staff member #1 stated staff member #2 wants to manage the patients pain medications.

In an interview with staff member #4 on 4/3/12 at approximately 5:15pm, the above was confirmed. It was also confirmed in the same interview that staff member #2 did have the order to be notified if patient #1's pain was not controlled with pain medication. Staff member #1 or staff member #2 was not notified and pain medication was prescribed to patient #1 without the consultation of staff member #1 or staff member #2. Staff member #4 also stated the nursing staff was now aware that staff member #2 wants to be notified when any patients are having problems with pain control.